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ophtho.corneal-abrasion.core.v1

Corneal abrasion & ocular-surface foreign body

general_internal_medicineacutesubacuteadultpediatricacuteoutpatientinpatient
Start encounter →Print handoutPRODUCTION

SIMPLE-ABRASION-framed engine — owns the benign epithelial defect + the contact-lens/organic/high-velocity risk-stratification that decides whether the patient is even on the simple-abrasion pathway. Intentionally distinct from ophtho.acute-red-eye.core.v1 (undifferentiated red-eye triage), ophtho.ocular-trauma.core.v1 (open-globe/orbital trauma) and ophtho.microbial-keratitis.core.v1 (ulcer/keratitis): different engine_id, different primary question. Penetrating injury / globe rupture, intraocular / retained FB, microbial keratitis / corneal ulcer, and herpetic dendritic keratitis are recognised then routed OUT by engine_id (ophtho.ocular-trauma.core.v1, ophtho.microbial-keratitis.core.v1, ophtho.acute-red-eye.core.v1, ophtho.acute-vision-loss.core.v1) — not re-authored here. Hard guardrails: NEVER pad/pressure a Seidel-positive or suspected ruptured globe (rigid shield); NEVER patch a contact-lens / organic / infected abrasion; NEVER MRI a suspected ferromagnetic IOFB; NEVER dispense a take-home topical anaesthetic; NO steroid for a herpetic dendrite. RxCUIs are well-established RxNorm ingredient/clinical-drug identifiers carried for the simple-abrasion ladder: erythromycin ophthalmic 4053, ciprofloxacin ophthalmic 2551, ofloxacin ophthalmic 7623, ketorolac ophthalmic 35827, cyclopentolate 3263, ibuprofen 5640, acetaminophen 161. Polymyxin B/trimethoprim is carried as a non_pharm combination entry (no single MIN). Flagged for next-session live RxNav re-confirmation per the research bundle. Bayesian linkage (pre-test simple-abrasion vs ulcer vs penetrating-injury priors by mechanism; LR for Seidel sign, hypopyon/infiltrate, contact-lens context, dendrite; CT-vs-no-imaging and ophthalmology-referral decision thresholds; bidirectional cross-engine routing edges by engine_id) is documented in the co-located _design-brief.md + _research-bundle.md; first-class TS LR fields remain schema-blocked (same constraint as the gold cellulitis template). Effect sizes (≥5): patching gives NO healing benefit and may be slower — RR 0.89 (95% CI 0.79-1.00) healed at 24 h, MD +0.14 days (Lim Cochrane 2016, PMID 27457359); topical NSAID cuts rescue oral analgesia RR 0.46 (95% CI 0.34-0.61), ~4/10 controls needing rescue at 24 h (Wakai Cochrane 2017, PMID 28516471); topical anaesthetics give very-low-certainty pain benefit and possibly MORE unresolved epithelial defects RR 1.37 (95% CI 0.78-2.42) (Sulewski Cochrane 2023, PMID 37555621); supervised short-course tetracaine Δ7 pain reduction (95% CI 6-8) with no healing difference 23.9% vs 21.3% (Shipman 2020 PMID 33121832 / Waldman 2014 PMID 24730399); ~2/90 ED abrasions progressed to corneal ulcer and ~29/90 had management changed by ophthalmology incl. recurrent-erosion treatment (Ross Can J Ophthalmol 2017, PMID 29217021).

Entry points (5)

  • symptom
    Acute unilateral sharp eye pain, foreign-body sensation, tearing and photophobia after trauma/FB (classic simple corneal abrasion — Cronau AFP 2010; Lim Cochrane 2016)
    acute_unilateral_eye_pain_foreign_body_sensation
  • history
    Contact-lens wearer with a painful red eye — ALWAYS treat as possible contact-lens microbial keratitis until excluded (Linaburg IDCNA 2024 — Pseudomonas-skewed; never patch)
    contact_lens_wear_with_painful_red_eye
  • history
    High-velocity mechanism — grinding, hammering metal-on-metal, drilling, lawn-strimmer — intraocular/retained-FB & globe-penetration prior is high (Sindal IJO 2017; AAO Eye Trauma)
    high_velocity_grinding_hammering_mechanism
  • history
    Organic / vegetative matter injury (branch, fingernail, plant, soil) — fungal-keratitis and recurrent-erosion risk modifies antibiotic choice & follow-up (Linaburg IDCNA 2024)
    organic_matter_or_vegetative_injury
  • symptom
    Recurrent sharp eye pain on waking/eye-opening weeks-months after a prior abrasion (recurrent corneal erosion syndrome — Ross Can J Ophthalmol 2017; Wang Eye Contact Lens 2022)
    recurrent_morning_eye_pain_after_old_abrasion

Required inputs (15)

  • mechanism_of_injuryrequired
    symptom • used at ENTRY
    Mechanism sets the pre-test prior: high-velocity grinding/hammering → IOFB/penetration; organic → fungal/erosion; contact lens → microbial keratitis; trivial scratch → simple abrasion (Sindal IJO 2017; Linaburg IDCNA 2024)
  • contact_lens_userequired
    history • used at CONTEXT
    Contact-lens wear is THE single finding that converts a "simple abrasion" into a microbial-keratitis-until-proven-otherwise pathway — never patch, low ulcer threshold, antipseudomonal cover (Linaburg IDCNA 2024)
  • visual_acuityrequired
    symptom • used at CONTEXT
    Documented visual acuity in EACH eye is the mandatory medico-legal and triage baseline; a central/large defect or media opacity dropping acuity escalates urgency (Cronau AFP 2010)
  • fluorescein_staining_patternrequired
    symptom • used at INITIAL_WORKUP
    Slit-lamp fluorescein under cobalt blue defines the epithelial defect; vertical linear "ice-rink" tracks → retained subtarsal FB; dendrite → herpetic; geographic with infiltrate → ulcer (Cronau AFP 2010)
  • seidel_signrequired
    symptom • used at RED_FLAGS
    Seidel test (fluorescein stream from a leaking wound) = full-thickness penetration / globe rupture — NEVER pad or pressure, shield + emergency, route OUT (AAO Eye Trauma; Cronau AFP 2010)
  • corneal_infiltrate_or_hypopyonrequired
    symptom • used at RED_FLAGS
    A white/grey stromal infiltrate, anterior-chamber cell or hypopyon means microbial keratitis / ulcer, NOT a simple abrasion — culture, intensive topical, never patch, route OUT (Linaburg IDCNA 2024)
  • lid_eversion_and_subtarsal_sweeprequired
    symptom • used at INITIAL_WORKUP
    Upper-lid eversion + fornix sweep is mandatory whenever an FB is suspected; a retained subtarsal FB causes vertical linear abrasions and non-healing (Cronau AFP 2010)
  • pupil_shape_and_anterior_chamberrequired
    symptom • used at RED_FLAGS
    A peaked/teardrop pupil, shallow chamber, or iris/uveal prolapse signals occult open globe — shield, no pressure, route OUT (AAO Eye Trauma)
  • tetanus_immunisation_status
    history • used at TREATMENT
    Tetanus prophylaxis is indicated for contaminated / penetrating ocular wounds; status is captured even for the simple abrasion pathway (CDC; AAO Eye Trauma)
  • occupation_eye_protection_use
    history • used at CONTEXT
    Grinding/welding/hammering occupation without eye protection raises IOFB prior AND drives the prevention/return-to-work counselling (AAO Eye Trauma)
  • pregnancy
    history • used at TREATMENT
    Antibiotic / analgesic safety gating — fluoroquinolone, oral NSAID and systemic-analgesic choices change in pregnancy (Cronau AFP 2010)
  • immunocompromise
    history • used at CONTEXT
    Immunosuppression / diabetes lowers the threshold for treating any defect as a developing ulcer and for ophthalmology referral (Linaburg IDCNA 2024)
  • pediatric_uncooperative_exam
    symptom • used at BRANCHING_WORKUP
    A child who cannot cooperate with slit-lamp may need exam under sedation/anaesthesia; consider non-accidental injury where the history is inconsistent (Cronau AFP 2010)
  • symptom_resolution_at_24_48h
    symptom • used at MONITORING
    A simple abrasion should be symptomatically and objectively healing by 24-48 h; non-healing pivots to retained FB / ulcer / erosion (Ross Can J Ophthalmol 2017; Lim Cochrane 2016)
  • prior_corneal_abrasion_or_erosion
    history • used at FOLLOWUP
    A history of prior abrasion + recurrent waking eye pain defines recurrent corneal erosion syndrome — lubricant/hypertonic ointment, debridement (Ross Can J Ophthalmol 2017)

12-phase flow (12)

  1. 1FRAME
    Frame as a SIMPLE epithelial defect that must FIRST survive a dangerous-look-alike screen (penetrating injury/globe rupture, intraocular/retained FB, microbial keratitis/ulcer, herpetic dendrite). Open-globe, IOFB and microbial-keratitis management are recognised then routed OUT by engine_id, not authored here.
    advance: simple-abrasion scope confirmed; not-this-engine concerns flagged for routing
  2. 2ENTRY
    Recognise the entry presentation and capture mechanism up front: trivial scratch vs high-velocity grinding/hammering vs organic/vegetative vs contact-lens vs recurrent-morning-pain. Mechanism is the dominant pre-test-prior driver (Sindal IJO 2017; Linaburg IDCNA 2024).
    inputs: mechanism_of_injury
    advance: entry trigger present; mechanism recorded
  3. 3CONTEXT
    Build the abrasion-vs-dangerous-mimic prior: contact-lens wear (→ microbial-keratitis pathway), occupation/eye-protection (→ IOFB), documented visual acuity per eye, immunocompromise/diabetes, organic-matter exposure. This phase decides whether the patient is even on the simple-abrasion pathway.
    inputs: contact_lens_use, visual_acuity, occupation_eye_protection_use, immunocompromise
    actions: workup.acute_red_eye
    advance: contact-lens / mechanism / acuity captured; simple-abrasion prior assigned
  4. 4RED_FLAGS
    Recognise globe-threatening look-alikes and route OUT (recognise, do NOT manage): Seidel-positive leak / peaked pupil / shallow chamber / uveal prolapse → ophtho.ocular-trauma.core.v1 (shield, NEVER pad/pressure, emergency); stromal infiltrate / hypopyon → ophtho.microbial-keratitis.core.v1; sudden vision loss / fixed pupil → ophtho.acute-vision-loss.core.v1.
    inputs: seidel_sign, corneal_infiltrate_or_hypopyon, pupil_shape_and_anterior_chamber
    actions: workup.acute_vision_loss, calc.news2
    advance: penetrating / IOFB / microbial / vision-loss red flags screened and routed by engine_id if positive
  5. 5INITIAL_WORKUP
    Fluorescein slit-lamp exam under cobalt blue: size, location, depth, pattern of the epithelial defect; mandatory upper-lid EVERSION + fornix sweep for a retained subtarsal FB (vertical linear "ice-rink" abrasions); rust-ring assessment for metallic FB; Seidel test. No routine bloodwork for an isolated simple abrasion.
    inputs: fluorescein_staining_pattern, lid_eversion_and_subtarsal_sweep
    actions: workup.acute_red_eye
    advance: defect characterised; lid everted + swept; subtarsal/embedded FB excluded or removed
  6. 6BRANCHING_WORKUP
    Decision tree: high-velocity grinding/hammering OR peaked pupil OR low acuity unexplained by surface → CT orbit for IOFB (NEVER MRI if metallic) + route to ophtho.ocular-trauma.core.v1; dendritic stain → herpetic keratitis (NO steroids) route to ophtho.microbial-keratitis.core.v1; embedded corneal/subtarsal FB → slit-lamp removal ± rust-ring burr; child unable to cooperate → exam under sedation + non-accidental-injury consideration.
    inputs: pediatric_uncooperative_exam
    actions: workup.acute_vision_loss
    advance: IOFB / herpetic / ulcer excluded or routed; FB removed; simple-abrasion diagnosis retained or reassigned
  7. 7DIFFERENTIAL
    Terminal differential with explicit pivots: simple corneal abrasion vs microbial keratitis/ulcer (infiltrate + AC reaction + contact-lens pivot) vs penetrating injury/globe rupture (Seidel + peaked pupil + low acuity pivot) vs retained intraocular FB (high-velocity mechanism + occult entry pivot) vs herpetic dendritic keratitis (branching dendrite + reduced sensation pivot) vs UV/chemical photokeratitis (bilateral + welding/snow + diffuse punctate pivot) vs recurrent corneal erosion (waking pain + prior-abrasion pivot).
    advance: single best diagnosis selected; contact-lens / organic / high-velocity modifiers carried forward
  8. 8RISK_STRATIFICATION
    Stratify the CONFIRMED simple abrasion for follow-up urgency: contact-lens-related, large/central, organic-matter, immunocompromised, monocular patient, or non-healing → mandatory next-day ophthalmology and low ulcer threshold; small peripheral traumatic abrasion in a non-lens-wearer → routine. NEWS2 only if associated systemic/major trauma.
    inputs: visual_acuity, contact_lens_use
    actions: calc.news2
    advance: follow-up urgency tier + ophthalmology-referral decision assigned
  9. 9TREATMENT
    Simple-abrasion treatment: (1) topical-antibiotic prophylaxis (erythromycin ointment / polymyxin-trimethoprim for non-lens; antipseudomonal fluoroquinolone — ciprofloxacin/ofloxacin — for contact-lens & organic); (2) oral analgesia ± short topical NSAID (ketorolac) for pain; (3) cycloplegic (cyclopentolate) for photophobic ciliary spasm if significant; (4) do NOT routinely patch (Lim Cochrane 2016 — no benefit, may be slower) and ABSOLUTELY do NOT dispense topical anaesthetic for home use (Tok 2015 / Shen 2020 — epithelial toxicity, ring keratitis, corneal melt); FB removal + shield-not-pad-if-rupture are non-pharm. Antibiotic/analgesic safety gating in pregnancy.
    inputs: tetanus_immunisation_status, pregnancy, contact_lens_use
    advance: prophylactic antibiotic + analgesia started; NO patch; NO take-home anaesthetic; 24-48 h recheck booked
  10. 10DISPOSITION
    Most simple abrasions: discharge with topical antibiotic, oral analgesia, return precautions and 24-48 h review. Contact-lens / large / central / organic / monocular / immunocompromised → next-day ophthalmology. Penetrating / IOFB / microbial-keratitis red flags → shield + emergency ophthalmology, route OUT by engine_id. Discharge NEVER includes a take-home topical anaesthetic.
    inputs: visual_acuity
    advance: disposition documented; no take-home anaesthetic dispensed; ophthalmology arranged if criteria met
  11. 11MONITORING
    A simple abrasion should improve symptomatically and on fluorescein by 24-48 h (most heal in 24-72 h — Lim Cochrane 2016). Non-healing or worsening at the 24-48 h recheck mandates re-exam for retained FB, evolving microbial keratitis/ulcer, herpetic disease or recurrent erosion BEFORE simply continuing — do not silently extend.
    inputs: symptom_resolution_at_24_48h, fluorescein_staining_pattern
    actions: workup.acute_red_eye
    advance: objective healing by 24-48 h, OR non-healing re-evaluation triggered (and routed if ulcer/IOFB)
  12. 12FOLLOWUP
    Recurrent corneal erosion prevention & counselling (the long-tail deliverable): for organic / fingernail / large abrasions or recurrent waking pain → prolonged lubrication, nocturnal hypertonic-saline ointment, consider epithelial debridement / bandage lens / referral (Ross Can J Ophthalmol 2017; Wang Eye Contact Lens 2022). Contact-lens hygiene + lens holiday; occupational eye-protection counselling for grinding/hammering; safe lens re-wear timing.
    inputs: prior_corneal_abrasion_or_erosion, occupation_eye_protection_use
    advance: erosion-prevention + lens-hygiene + eye-protection counselling documented; ophthalmology referral made if criteria met